IOTW 11/23/20

67 y/o F p/w RUQ pain

  1. What are the three structures that compose the portal triad?
    • Portal vein, hepatic artery, and common bile duct. The common bile duct will not exhibit flow when evaluated with color doppler.
  2. Which structure is indicated by label “A”?
    • The common bile duct. Note the absence of flow with color doppler.
  3. What is the name of the artifact indicated by label “B”?
    • Acoustic shadowing. Ultrasound waves are absorbed by a solid structure or reflected off of air, causing “clean” or “dirty” shadowing, respectively.
  4. What is the normal diameter of structure “A”? What about if the patient is post-cholecystectomy?
    • The CBD should measure <6 mm in diameter and the upper limit increases by 1 mm per decade after age 60. Post-cholecystectomy CBD may measure up to 10 mm (1 cm) in diameter. Be sure to measure from inner wall to opposing inner wall in a perpendicular fashion.
  5. What is the diagnosis hinted at by label “C”?
    • Choledocholithiasis. The CBD is grossly enlarged and measures about 9-10 mm in diameter when compared with the scale on the right-hand side of the screen. Label “C” indicates a visualized stone within the CBD distally which appears as an echogenic rounded focus with shadowing.
  6. Do these images suggest the presence of concomitant acute cholecystitis?
    • No. Sonographic evidence of cholecystitis includes stone in neck (SIN sign), anterior gallbladder wall thickening, pericholecystic fluid, gallbladder hydrops, and sonographic Murphy’s sign, none of which are present. There are numerous small gallstones within the gallbladder, however, which should at least raise suspicion for other biliary tract obstruction.
  7. Which diagnosis would you be most concerned about if the patient exhibited signs of infection?
    • Ascending cholangitis. The classic Charcot’s Triad (fever + jaundice + RUQ pain) only occurs in ~50% of patients and the classic Reynold’s Pentad (triad + altered mental status + hypotension) only occurs in <5%. In elderly patients, hypotension may sometimes be the only presenting sign, so a high index of suspicion must be maintained. If the diagnosis is likely, patients should be treated aggressively for sepsis with fluid resuscitation and antibiotics targeted at organisms such as E. coli, Enterococcus, Bacteroides, Clostridium, and even MRSA in severe cases. The case should be coordinated with gastroenterology and general surgery for ERCP and cholecystectomy to achieve source control and biliary decompression.

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